The present invention relates to the treatment or prevention of seborrheic keratosis of the skin with locally applied formulations; in particular topical formulations. Furthermore, it relates to topical formulations suitable for this purpose.
Seborrheic keratosis is one of the most common non-cancerous, benign, epidermal skin tumors. It is a harmless skin growth that originates in keratinocytes of the epidermis. Keratinocytes are the predominant cell type in the epidermis, the outermost layer of the skin, constituting 80% of the cells found there. Those keratinocytes found in the basal layer (stratum basale) of the epidermis are sometimes referred to as “basal cells” or “basal keratinocytes”.
The primary function of keratinocytes is the formation of a barrier against environmental damage such as pathogens (bacteria, fungi, parasites, and viruses), heat, UV radiation and water loss. Keratinization is part of the physical barrier formation (cornification), in which the keratinocytes produce more and more keratin and undergo terminal differentiation. The fully cornified keratinocytes (corneocytes) that form the outermost layer, the stratum corneum, are constantly shed off and replaced by new corneocytes.
Within the epidermis, keratinocytes are associated with other cell types such as melanocytes and Langerhans cells. Keratinocytes modulate the immune system and are potent producers of anti-inflammatory mediators (such as IL-10 and TGF-β). Keratinocytes also contribute to protecting the body from ultraviolet radiation by modulating the skin pigmentation, taking up and storing melanosomes, vesicles containing the endogenous photoprotectant melanin, from epidermal melanocytes.
Seborrheic keratosis occurs in form of so-called growths, or lesions, (which are also referred to as seborrheic keratoses), which may be found in many areas of the body, including the face, ears, neck, arms, chest, shoulders, back and stomach as well as the back of the hands. Unlike warts, though, they are usually not found on the soles of the feet or the palms.
The lesions may be round or oval in shape and feel either slightly elevated (e.g. like scab on a healing wound) or completely flat. The formation of the lesions typically involves hyperkeratosis and acanthosis (a diffuse epidermal hyperplasia; i.e. a thickening of the epidermis by increased proliferation of cells in the stratum basale and stratum spinosum). They often start as small flat, rough areas, and over time develop a thicker, exophytic, sometimes fissured, wart-like surface, which may have a waxy, greasy, sebaceous appearance; thus the term “seborrheic”. Sometimes, pseudo-cystic inversions and inclusion of horn-globules may be seen in/on the lesion. Mostly, the lesions look as if they were pasted onto the skin, because they have well-defined demarcation lines to the surrounding skin and typically only the top layers of the epidermis, i.e. the outermost layer of our skin, are involved in their formation. The size of the lesions ranges from very small ones of only a few millimeters up to more than 2.5 centimeters.
The lesions may have various colors, ranging from white or yellow, light tan to dark brown, sometimes black, depending on the extent of melanin content. Rarely, they may also be white or yellow. Although seborrheic keratoses are often associated with increased pigmentation and may resemble moles, nevi, liver spots or lentigos, they have to be distinguished from such melanocytic hyperpigmented tumors/lesions which are caused by a dysfunction of melanocytes. Unlike e.g. nevi (which are based on an abnormal proliferation of melanocytes located on the basal layer of epidermis, the junctional zone between epidermis and dermis), seborrheic keratosis originates in the keratinocytes as mentioned above.
In some cases, seborrheic keratosis lesions may further be difficult to distinguish from melanoma, a very serious type of skin cancer, which is why they should be checked by a dermatologist in case of doubt.
Seborrheic keratoses are also known as “seborrheic verruca”, “or “seborrheic warts, “senile warts”, “benign acanthokeratosis” and as “basal cell papilloma”. However, these terms used for seborrheic keratosis are misleading. Firstly, seborrheic keratosis is not limited to a seborrheic distribution (scalp, mid-face, chest, upper back), nor are they formed from sebaceous glands as is the case with sebaceous hyperplasia. Secondly, seborrheic keratosis has nothing in common with warts (verruca), they are not of viral origin and are not associated with the human papilloma virus. The term “senile wart” is also a misnomer. Although the onset is usually in middle age (over 40) they are a common finding also in younger patients; e.g. 12% of the 15-25 year-olds (Gill D., Dorevitch A., Marks R.; The prevalence of seborrheic keratoses in people aged 15 to 30 years: is the term senile keratosis redundant? Arch. Dermatol. 2000 June; 136(6):759-62).
Variants of seborrheic keratoses include Stucco keratoses: numerous small dry grey stuck-on lesions usually found on lower legs and feet; Dermatosis papulosa nigra: numerous brown, warty papules on face, neck and chest of dark-skinned individuals; Irritated seborrheic keratoses: inflamed lesions, often red and crusted which may resemble a skin cancer; and Lichenoid keratosis: resolving keratosis or lentigo, often pink or grey-colored.
The cause of seborrheic keratosis, or the exact mechanism of the formation of seborrheic keratosis lesions, is not known. Seborrheic keratoses are considered degenerative in nature, appearing as part of the skin aging process. As time goes by, seborrheic keratoses become more numerous. Men and women are affected alike. Some people inherit a tendency to develop a very large number of them.
The majority of lesions appear on skin areas which are usually covered by clothes, such as chest, shoulders, back and stomach; thus UV-light exposure does not seem to be the cause of seborrheic keratosis lesions. Other external factors, physical and/or chemical, do not seem to foster seborrheic keratosis.
And neither the presence nor absence of any specific protein is unique to seborrheic keratosis. The lesions are believed to consist of accumulated senescent epidermal cells in G1-phase arrest of the cell cycle that histologically fail to differentiate like normal epidermal basal cells, although they do multiply, keratinize, and mature into squamous cells. Immuno-histochemical analyses have shown differences between lesion cells and normal skin cells in cytokeratins, involucrin, ras p21, and epidermal transglutaminase expression. Seborrheic keratosis cells were further found to have increased expression of interleukin-2, tumor necrosis factor-a, endothelin-converting enzyme-1 α, p73, interferon-γ, and lymphotoxin mRNA and down-regulation of IL-l α compared with peri-lesional normal epidermis.
The fact that seborrheic keratosis often runs in families, with the risk increasing with the number of affected relatives, suggests a certain genetic disposition. Newer studies, for example, indicate a frequent activating mutation of the FGF-receptor (fibroblast growth factor) as a possible mechanism. Others propose a cyclin-dependent kinase inhibitor, p16, that is expressed in all lesion cells, or an imbalance in the p53 and Bcl-2 proteins; all leading to suppression of apoptosis, and hence accumulation of cells (Burkhart et al.; “Use of a keratolytic agent with occlusion for topical treatment of hyperkeratotic seborrheic keratoses”; SKINmed: Dermatology for the Clinician, Vol. 7, Issue 1, p. 15-18, January/February 2008).
Seborrheic keratosis lesions are benign, non-contagious and—unlike e.g. nevi—do not develop to (pre)-cancerous stages. Only very rarely, eruptive seborrheic keratoses may denote an underlying internal malignancy, e.g. gastrointestinal adenocarcinoma. The syndrome is known as the sign of Leser-Trélat. A dermatologist may decide to remove one or more lesions for differential diagnosis purposes if they have a suspicious appearance, or simply if they are causing physical or emotional discomfort to the patient; e.g. if the lesions are considered unsightly and/or if lesions interfere with clothes, jewelry, razors during shaving or the like, which may lead to bleedings and infections. This physical or emotional discomfort of the patient is often so intense and long-lasting, that the patients express a strong desire to get rid of the lesions or to at least reduce their size and/or coloration.
Commonly used removal methods include cryo-therapy, electro-therapy, curettage and laser treatment (e.g. using erbium-YAG-lasers). During cryo-therapy the lesions are sprayed or swabbed with liquid nitrogen which causes them to freeze, form minor blisters and flake off during the subsequent days or weeks. With electro-therapy the lesions are treated with an electrical current causing them to desiccate and/or evaporate. Electro-therapy may be combined with curettage, which means scraping the lesions off using a sharp spoon or a sling; the latter may apply an electrical current on the lesion while scraping it off to prevent bleeding. This is also called cauterization. Typically the area is numbed before the procedure. Nonetheless, the methods are invasive, painful and associated with certain risks such as scarring and skin discoloration.
Some online shops offer herbal pills for oral ingestion to target seborrheic keratosis, such as Kenofax, Rhinical, Sebeton or Sebarec. These pills contain a wide range of plant extracts from e.g. Swertia Chirata, Fumaria Officinalis, Tephrosa Purpurea, Sphaeranthus Indicus, Zizyphus Vulgaris, Terminalia Chebula, Cassia Absus, Melia Azadirachta, Lycopodium Clavatum, Berberis Aristata. While presumably common in the Himalayans, the majority of these plants are not considered approved and well-known medicinal plants throughout Europe or North-America. Thus, apart from the apparent lack of toxicity studies for these pills and the potentially doubt-worthy manufacturing methods- and sites, there remains the risk of allergic reactions to one or more of the multicomponent mixtures in said pills. Furthermore, they do not provide for a topical or local treatment which is preferred by many in order to limit undesirable side effects.
Some topical formulations applied in the (cosmetic) treatment of e.g. skin discolorations and/or skin diseases associated with hyperkeratosis have been disclosed in the prior art.
For instance, WO 2012/080466 describes ingenol compounds, such as ingenol-3-angelate, and their topical use in treating seborrheic keratosis. The ingenol compounds are e.g. administered in the form of an isopropyl alcohol-based gel.
Herron et al. tested topical formulations of typical psoriasis drugs on seborrheic keratosis lesions in daily or bi-daily application regimens: calcipotriene (0.005% ointment), tazarotene (0.1% cream) or imiquimod (5% cream) (“Seborrheic keratoses: A study comparing the standard cryosurgery with topical calcipotriene, topical tazarotene, and topical imiquimod”; Int. J. Dermat.; Vol. 43, Issue 4, pages 300-302, April 2004). Herron et al. tried to benefit from calcipotriene's and tazarotene's promoting effects on keratinocyte differentiation and their antiproliferative effects, as well as imiquimod's immune modulatory effect which was successful with refractory warts and molluscum contagiosum, and neoplasms such as pre-malignant keratosis and squamous cell carcinoma. The results were not satisfactory: once daily application of calcipotriene, tazarotene and imiquimod did not result in any clinical improvement. And bi-daily application of tazarotene caused clinical and histological improvement in less than half the patients only. In addition, effectiveness of tazarotene was limited by its irritation, with ⅔ of the patients reporting burning, pruritus and redness. Furthermore, tazarotene, as most retinoids, is not allowed during pregnancy and women of childbearing potential would have to use adequate birth control measures when using tazarotene topically.
U.S. Pat. No. 7,381,427 B2 discloses topical compositions and methods for the treatment, removal, elimination and prevention of seborrheic keratoses utilizing safe, dependable, effective, biocompatible treatments with no scarring, bleeding, burning, freezing, shocking, and hypopigmentation or hyperpigmentation; said treatments involving the use of high concentration hydrogen peroxide as the active agent (at least about 23%; e.g. 43-48%). Optionally, the compositions may further contain vitamins, amino acids, melanin inhibitors such as kojic acid, organic acids such as lactic acid, and hormones such as melatonin and/or various other components. It is noted that U.S. Pat. No. 7,381,427 B2 is silent on artemisinin or its derivatives or similar plant extracts from the same family. Additionally, more than once the authors mention seborrheic keratoses that have become malignant or are at risk of becoming malignant, which according to common knowledge on seborrheic keratosis does not occur with these types of lesions. This may indicate that the authors give the term seborrheic keratosis a much broader meaning than has been established in the scientific community, e.g. also covering other skin-conditions such as nevi which have a different etiopathogenesis from seborrheic keratoses as commonly defined.
Burkhart et al. reported in 2008 that still no topical treatment was commonly recommended for seborrheic keratosis lesions and thus tested 50% urea under occlusion in order to treat unsightly lesions (“Use of a keratolytic agent with occlusion for topical treatment of hyperkeratotic seborrheic keratoses”; SKINmed: Dermatology for the Clinician, Volume 7, Issue 1, pages 15-18, January/February 2008). Keratolytic substances such as urea, salicylic acid, lactic acid and retinoic acid are known to the skilled person since a long time and have been applied in form of e.g. creams, ointments, pastes, solutions and lacquers; e.g. in order to soften the skin's keratin and thereby treat warts and other lesions in which the epidermis produces excess skin. While no side effects were reported, the success of applying urea and digitally scraping the lesions was limited: some reduction of the thickness of seborrheic keratosis lesions could be achieved but lesions did persist albeit with reduced size. Burkhart et al. further admitted that the selection of patients who were very frustrated with the condition and desired any assistance with their malady may have partially biased the study responses; i.e. even the smallest treatment success was rated very positive. This highlights the strong-felt need of a topical treatment for seborrheic keratosis.
US 2010/0061948 A1 discloses the treatment of skin discolorations in general using skin-whitening compositions comprising artemisinin. Artemisinin (also called Qinghaosu in traditional Chinese medicine) is a sesquiterpene lactone with a peroxide group, which has hitherto been examined and used mainly as a systematically active antimalarial drug. Artemisinin is very hard to dissolve in water; however, more water-soluble derivatives of artemisinin, such as dihydroartemisinin or artesunate have been developed. According to US 2010/0061948 A1, artemisinin allegedly suppressed melanin synthesis and tyrosinase activity to inhibit pigmentation of melasma and freckles. However, the etiopathogenesis of melasma and freckles differs from that of seborrheic keratosis. For example, unlike seborrheic keratosis lesions, freckles (also called lentigo solaris) and melasma are disorders of melanocytes and promoted by sun-light; melasma are further often triggered by drugs such as contraceptive hormones. US 2010/0061948 A1 remains silent on seborrheic keratosis; and the mere suppression of pigmentation alone would not solve the hyperkeratosis, the causation of the lesions, which often leads to clothes, jewelry or razor blades getting caught on seborrheic keratosis lesions, in particular the exophytic ones.
Another skin-whitening composition is described in US 2013/0259815 A1. The application discloses methods of lightening skin by applying certain aromatic compounds to the skin, or botanical extracts containing such compounds, e.g. Acronychia acidula extracts. Various skin conditions in need of lightening (or whitening, brightening, evening of skin tone, reduction in sallowness) are described; mainly hyperpigmented marks and/or lesions including, but not limited to, pigmented spots, melanin spots, age spots, sun spots, senile lentigos, freckles, lentigos simplex, pigmented solar keratosis, seborrheic keratosis, melasma, acne marks, post-inflammatory hyperpigmentation, lentigines, ephelides, combinations of two or more thereof and the like. However, US 2013/0259815 A1 is silent on Artemisia Annua extracts and/or artemisinin or derivatives thereof.
U.S. Pat. No. 8,193,376 B2 described formulations, suitable for oral and topical application, for the treatment of infections and topical ailments, such as acne, rosacea, skin discolorations and age spots. The formulations comprise certain derivatives of artemisinin (and other active principles contained in Artemisia Annua extracts) with amino acids, peptides, and amino sugars, as well as isomers and salts thereof according to formula:
which possess wide-spectrum antibacterial and antifungal biological activity.U.S. Pat. No. 8,193,376 B2 further describes artemisinin and its derivatives as having virucidal or virustatic, anti-malarial, anti-cancer and anti-protozoan properties. However, unlike the described acne and rosacea seborrheic keratosis does not involve any bacterial, viral or parasitic infection; and it further does not involve a cancerous degeneration of cell. Thus, seborrheic keratosis would not benefit from any of the properties of artemisinin (or its derivatives) disclosed in U.S. Pat. No. 8,193,376 B2.
Further artemisinin formulations for topical, oral or parenteral application are disclosed by Thornfeldt in e.g. U.S. Pat. No. 4,978,676 A or JPH03-170422. The inventor successfully applied artemisinin and its analogues topically for the treatment of three psoriasis patients; and then further assumed that said compositions should also be effective against hemorrhoids, tubercles, malignant melanoma, keratosis before getting malignant, malignant mole, basal cell cancer, viral tumors (e.g. warts, molluscum contagiosum and orf (Ecthyma contagiosum)); as well as UV-induced skin conditions and tumors (e.g. blistering skin diseases such as xeroderma pigmentosa, pemphigoid or pemphigus; polymorphous light eruption; collagen vascular diseases such as Lupus erythematosus, mixed connective tissue diseases or dermatomyositis; Bowen's disease or squamous cell cancer). However, Thornfeldt does not provide any mechanistic details which would elucidate the relationship between all the above mentioned diseases and/or why all of them would be likely to respond to a treatment with artemisinin or its derivatives. He is further silent on seborrheic keratosis; and none of the disclosed diseases is associated with seborrheic keratosis. (The term “keratosis before getting malignant” in the abstract of JPH03-170422 clearly refers to only those types of keratosis which—unlike seborrheic keratosis—are capable of degenerating to a malignant stadium; e.g. the pre-cancerous and typically UV-induced actinic keratosis).
In EP 1940383 B1 the use of artemisinin or its derivatives in topical formulations is disclosed for the treatment of benign pigmented moles; in particular those of melanocytic origin, such as melanocytic nevi (acquired and congenital), lentigines (sun age spots) or disorders of pigmentation and pigmented macules of the mucous membranes. However, EP 1940383 B1 does not mention seborrheic keratoses. As indicated earlier, seborrheic keratosis and melanocytic lesions (nevi, lentigines) differ significantly in their etiology and pathogenesis. In contrast to melanocytic lesions, seborrheic keratoses are epithelial and not melanocytic proliferations. The melanin pigment in seborrheic keratoses is housed in keratinocytes and not in melanocytes. Seborrheic keratoses are epidermal proliferations that are typified by acanthosis associated with increased number of keratinocytes and papillomatosis of the epidermis that can trigger an increase in the production of melanin in melanocytes and an increased pigmentation of keratinocytes. Keratinocytes in some seborrheic keratosis have been found to harbor specific mutations that are completely different from those found in melanocytic nevi. Melanocytic lesions (nevi, lentigines) on the other hand are melanocytic proliferations characterized by increased numbers of melanocytes and pigmentation. Typical for nevi is the formation of nests of melanocytes in the epidermis or in the dermis and their hyperpigmentation is caused by a substantial increase in the number of melanocytes. As of current knowledge, seborrheic keratoses usually will not turn malignant, while—albeit rarely—a melanoma may develop in a preexisting melanocytic nevus.